Hypertriglyceridemia: A strategic approach
This review, and the at-a-glance tables that follow, detail indications and strategies for the treatment of adults with hypertriglyceridemia.
PRACTICE RECOMMENDATIONS
› Evaluate patients for hypertriglyceridemia when they have a comorbid condition (eg, type 2 diabetes, obesity, hypothyroidism, metabolic syndrome, alcoholism). B
› Do not require fasting status when evaluating triglycerides in a lipid panel. B
› Make therapeutic lifestyle changes first-line treatment for hypertriglyceridemia. C
› Prescribe fibrates for severe hypertriglyceridemia to reduce the risk and recurrence of pancreatitis. A
› Prescribe a statin and an omega-3 fatty acid (fish oil) to lower the triglyceride level and thus reduce resulting atherogenicity when the risk of atherosclerotic cardiovascular disease is > 7.5%. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
How HTG is defined: Causes, cutoffs, signs
HTG is most commonly caused by obesity and a sedentary lifestyle; certain associated comorbid medical conditions can also be a precipitant (Table 11,2). Because the condition is a result of polygenic phenotypic expression, even a genetically low-risk patient can present with HTG when exposed to certain medical conditions and environmental causes.
Primary HTG (genetic or familial) is rare. Genetic testing may be considered for patients with TG > 1000 mg/dL (severely elevated TG = 500 to 1999 mg/dL, measured in fasting state*) or a family history of early ASCVD (TABLE 11,2).2,3
Typically, HTG is asymptomatic. Xanthelasmas, xanthomas, and lipemia retinalis are found in hereditary disorders of elevated TGs. Occasionally, HTG manifests as chylomicronemia syndrome, characterized by recurrent abdominal pain, nausea, vomiting, and, in severe HTG, pancreatitis.3
Fine points of TG measurement
Triglycerides are a component of a complete lipid profile, which also includes total cholesterol, calculated low-density lipoprotein (LDL-C), and HDL.4 As in both case vignettes, detection of HTG is often incidental, when a lipid profile is ordered to evaluate the risk of ASCVD. (Of note, for people older than 20 years, the US Preventive Services Task Force no longer addresses the question, “Which population should be screened for dyslipidemia?” Instead, current recommendations answer the question, “For which population should statin therapy be prescribed?”5)
Effect on ASCVD risk assessment. TG levels are known to vary, depending on fasting or nonfasting status, with lower levels reported when fasting. An elevated TG level can lead to inaccurate calculation of LDL when using the Friedewald formula6:
LDL = total cholesterol – (triglycerides/5) – HDL
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